Military trauma management

National Jewish Hospital is not a trauma hospital, in fact it doesn't even have beds for overnight stays except in pediatrics. But it has a diverse set of doctors and one I spoke with today fascinated me with military trauma information. His name is Dr. Richard Meehan and he is a rheumatologist who also spent time in Iraq as a critical care physician. He describe some very interesting details about the day-to-day of the soldiers in the field. These are some observations from that discussion.



Each individual soldier is now expected to care for himself during active combat. In a combat situation medics are usually not deployed to soldiers, as we all know from the movies. Nobody calls out "medic" when they are hit or hurt in combat because the military has learned that the next person to be targeted for kill will be the medic. Apparently a medic is a valuable target since killing the medic means no more care for all the other soldiers and a dead medic is terrible for the moral of the guys fighting.



So each soldier carries a medical pack including an airway to let a comrade, who is choking on his tongue, breathe, a tourniquet, a dressing that has clotting material impregnated in it for bleeding (apparently this hurts like hell since the clotting factor generates heat, but it's this or bleed to death), a large needle to allow decompression of a collapsed lung, antibiotics and pain medicine. The tourniquets are designed so the soldier can put it on with one hand.



Once fighting has stopped medics will be available and they carry more equipment including an eye trauma kit, an otoscope (if a soldier suffers head trauma from an IED an indication for evacuation is a ruptured ear drum), suture kits, and lots of tourniquets and impregnated dressings, medications including narcotics that they sign out immediately before hitting the field and sign in immediately upon returning, moldable splints and dressings for sucking chest wounds. This is called is called an Ashleman's Patch and works by creating an airtight seal on the chest while the patch has a one way valve to let air leave an open chest wd but doesn't allow air into the chest. This allows for the lung to re-expand.



Soldiers are taught triage as follows: if a fellow soldier is not breathing they are considered dead, there is no way for advanced life support to be administered in the field (although I expect there can be exceptions to this), if someone is having difficulty breathing-a soldier applies the airway in their personal kit, positions the soldier on his/her left side and moves on. A soldier is expected to STOP ALL BLEEDING with dressings and tourniquets. This is a huge source of morbidity and mortality in the field. As Dr. Meehan commented, "Of the A(airway)-B(breathing)-C(circulation)s of life support, the C becomes most important in the field.


A soldiers helmet is designed with gel shock absorbers that limit risk for intracranial bleeding.

The smell of cattle before the storm.

This will be short. The smell of cattle dung seems to be the harbinger of a storm. I don't completely understand this but it smells like cattle before it storms in Denver. I asked the staff at the restaurant where I ate at about 6pm tonight, "why does it smell like a stable tonight?" They remarked that every time they expect snow in Denver it smells like a horse or cattle stable because the prevailing winds bring the smell of rural Colorado or a Purina processing plant into Downtown area. Weather experts predict 6 inches of snow to Denver tonight. Wow. What a travel fact. It smells like the Minnesota State Fair here, and it has started to snow.

Evolution: Back in time?

This has been a difficult but very cool subject. National Jewish is not only a clinical center but seems to have a "think tank" quality to it as well.

Evolution has been accepted as a product of Darwin and natural selection but with recent discoveries of the human genome, genetics, evolution and molecular biology there may be some devolution in evolution. Before I start let me tell you about a scientist by the name of Jean Baptiste Lamarck. He lived a generation before Darwin and worked as a French biologist. His theory of adaptation in animals contradicted Darwin, or vice versa. Darwin, in his theory including natural selection, argued that the environment selects out survivors who then pass their surviving genes on to the next generation, who pass their genes on etc. With mutations and the like that may make generations even more resilient in the future.

Lamarck believed that organisms adapt to their environment within the lifetime of the organism. For example a giraffe may grow a longer neck if it finds itself in an environment with tall trees. Darwin and his colleagues debunked this theory and we have his thoughts lasting through history until now.

Well, in fact the two may act in accordance with each other. Nature v. nurture, it seems, is being defined in a way that makes scientific sense, not just in a way that would make sense to your mother. Mine would say, "you don't need science to know that." But it's nice that science can prove it...I think.

Dr. Choudry of the University of California, San Francisco, studied Latinas from Puerto Rico and Mexican-Americans. Puerto Ricans have individual ancestry predominantly from Africa and Native Americans and Mexicans have individual ancestry from Europeans and Native Americans. Under all measures asthma severity was more prevalent in Mexican Americans when compared to Puerto Ricans. And there seemed to be a correlation between the amount of European ancestry in Mexican Americans and asthma severity. Interestingly, there was a reverse correlation based on the amount of Native American ancestry in both groups, i.e. the more Native American ancestry one has the less severe asthma. This suggest that ancestry plays a role in asthma. But, Dr. Busse of the University of Wisconsin, and others, have shown that "stress" can lead to changes in the immune system, airways and the brains of those with asthma leading to more severe asthma attacks when confronted with something that precipitates asthma. Nature v. nurture.

In tuberculosis, Dr. William Stead showed that that African-Americans in prisons and nursing homes were more prone to be infected with TB than those of European ancestry. But both groups developed active TB at the same rate. Interesting? Why? Nobody seems to know but many believe that it depends on the genetic make up of the different groups. This seems to be the nature part of nature v. nurture. The part that Darwin may have been very attentive to. The Europeans were apparently the first to encounter TB on a large scale because of their propensity to live with cows and to drink milk. TB is thought to derive from cows long ago. Over generations Europeans may have been passing genes on that are protective against TB infection. An extreme example of "genetic protection" occurred in New Guinea in the 1950s when TB was introduce to their island and decimated many. They were naive to TB and did not have the generations of exposure for natural selection to occur.

I have been a true believer in the predominance of natural selection in evolution until now. It seems that a certain Lamarckian aspect to evolution is creeping into the thoughts of scientists. These are people, who unlike me, probably don't go to many movies or watch sports every week-end because they work. These incredibly smart scientists, like Dr. David Schwartz at National Jewish, are presenting data that suggests the environment may actually change the way genes are expressed in things and this may change the way an organism adapts to its environment, not over generations, but within the life of the organism. This would be the nurture part of nature v. nurture. Although when I asked him specifically about Lamarck he did not think we would go back to that thinking, back to that idea that a giraffe could grow a longer neck to get to the leaves.

But the literature seems compelling enough to at least make me think that pure natural selection may not be so accurate in the evolution of organisms. Although I had a hard time understanding the detail of papers presented on this subject I did glean some useful information to make me believe in a more Lamarckian bent.

The building blocks of genes are nucleic acids and genes contribute to the production of amino acids that are the building blocks of protein, which in turn are the building blocks of organisms. Genes can be turned on and off depending on many things, many I don't understand, but it seems that the level of methylation (a methyl group looks like this...-CH3, where C is carbon and H is hydrogen) and the array of histone acetylation (histones are proteins that wrap around and within genetic material and an acetyl group looks like this...-COOH, where O is oxygen) play a significant role in interpreting what should be made.

In identical twins that look the same at birth it has been shown that over time they will diverge in appearance, much like my friends the Golden brothers who are identical twins. They are both bald, sorry guys, but have different appearance such that it is possible to tell them apart at their ripe age of 47. Dr. Frage, in a paper from Spain, showed that the level of methylation and histone acetylation is different in identical twins of old age and this change occurs as a consequence of environment. Not only that but once a cell has changed it will continue to divide with these changes intact. These changes of methylation, etc. are called epigenetics and epignetics can change the way proteins are made in a gene structure that is exactly the same. This can be observed in plants as well. When a blooming plant is taken to high altitude or to a cold environment it will bloom differently than one in your house. This is thought to be related to the way biochemistry changes at altitude or with temperature. Carbon, oxygen, nitrogen and hydrogen act differently depending on the environment. The Goldens look different because they have had different lives, one is a lawyer and sailed in the navy, and the other has been a fireman in the Midwest.

Finally, if you give pregnant mice a diet high in folate, a vitamin that will induce methylation of genes, the offspring will come out with differing colored coats depending on the level of folate given.

So I am becoming more convinced that the old adage nature AND nurture contribute to the appearance of an organism, and perhaps the way it may respond to disease, and Lamarck may have been onto something when he thought that an organism can "change" within its lifetime to adapt to its environment. I still respect Darwin. Now let's talk religion...

Buffalo to Red Rocks Amphitheater

Yesterday I wanted to get a photo of a buffalo framed so I went to the mall, Cherry Creek. I lost the photo in an Eddie Bauer store and spent most of my mall time retracing my steps to find it. The clerk at the Eddie Bauer was disappointed that I returned because he was going to keep it, as he said, "That would have made my day". I offered to sell it to him but he declined. I now have collection of American buffalo photos.

The American buffalo is more related to cattle and the European buffalo that to the "original" buffalo from Asia and Africa. They are more like oxen in those continents but I don't understand taxonomy enough to know the difference so rather than refer to them as bison, the proper reference apparently, I have chosen to continue to refer to them as buffalo.

At one point the American buffalo herd extended from the far Northwest of Canada to the Appalachian mountains and there is evidence that they were in the Southeast as well. In the late 19th century they were nearly extinct but now are abundant in the US West. The only original wild buffalo herds are in Yellowstone Park. The rest apparently are owned by somebody.

They can be as big as 2500 lbs., have gestation of 285 days, are herbivores and live about 15 years.

Before horses were introduced to North America Native tribes would herd them over cliffs to kill them for food, pelt, and bony weapons. In Alberta, Canada there is a historic jump called Head-Smashed-in Buffalo Jump.

With horses and bow and arrow the plains Indians would hunt them in abundance. From previous reading I understand that buffalo have a "noncompartmentalised" thoracic cavity allowing both lungs to collapse with one arrow, leaving the buffalo dead in its tracks. Human and most other mammals have compartmentalised thoracic cavities that save one lung for function if we are shot, or stabbed, or suffer collapse of a lung from disease.

Both Native Americans and the US government contributed to the buffalos near extinction. The Commanche in the Southern Plains were reported to kill 280,000 buffalo in one year. The US government allowed the unfettered slaughter of buffalo in the 19th century partly to limit the food source for Native Americans.

In case you haven't noticed buffalo are uuuggglllyyy. That's why I posted two pictures...for your notice.

Today I went to Red Rocks Amphitheater with my friend Tim, his wife Ginny and their daughter Meg (aka Peggy). Red Rocks is a natural collection of red rock, surprisingly so. It was thought to be a gathering area for the Ute tribe before it was so rudely borrowed by a gentleman named John Brisbane Walker in 1906. He was an editor and used the money he made from the sale of Cosmopolitan Magazine (probably not like the Cosmo some know and love today). The first public performance by "settlers" was Pietro Satriano and his 25 piece brass band. I don't have a read on the attendance. The earliest notable rock concert there was by the Beatles in 1964, purportedly the only concert they did not sell-out in North America.

Other notable acts have included John Denver (of course!), Pat Boone, the Carpenters, Grateful Dead (probably more than once), Jethro Tull (where rock throwing and tear gas were involved), REM, Coldplay and probably most notable bands of the last 50 years.

U2 recorded a concert there called Red Rocks:Under a Blood Red Sky and Steve Martin recorded his comedy album "Wild and Crazy Guy" there. Dave Mathews has probably played there nearly as much as he has played the Gorge.

After Red Rocks we had dinner at a place called the Fort where we shared a platter of Rocky Mountain Oysters, buffalo sausage, beef tongue and I had a wonderful buffalo prime rib followed by buffalo ice cream and rattlesnake cake. OK, the last two are made up but there sure was a lot of buffalo meat being served. Did you know that buffalo can reproduce with cattle? No one would want to see that.

How National Jewish got its name?

I remember Dr. Mike Iseman (a respected TB expert at National Jewish) coming to Bellevue Hospital to speak and to attend our TB case conferences when I was on the Chest Service there, circa 1993. He once told us how National Jewish got its name but I'll be flakskdfuakjlejed if I could remember what he said. I remember everything else he said (this is pure sucking up just in case he reads the blog, so I didn't really remember everything he said but I wish-since he's a bright guy-there I go again, make me stop!) Anyway I picked up some books to understand the distant history of National Jewish.

There are two books that outline the development of National Jewish and TB medicine in Denver, A Place to Heal by Mary Ann Fitzharris and Blazing the Tuberculosis Trail by Jeanne Abrams.

In 1858 there was a gold rush in the area and the Jewish community became well established in Denver, primarily with reasonably well-off, or middle to upper middle class Jews of German decent. In the 1880s many others came to Denver for its dry and sunny air. This was especially true of those with TB since it was thought that sun and fresh air was good for those with TB. At one point in the late 19th century it was believed that 60% of the immigrants to the area had TB or were family members of those with TB. In a way it was becoming the "world's sanatorium".

Two key people contributed to the development of a hospital and campus dedicated to the treatment of those with TB and their family. Frances Wisebart Jacobs was an activist who travelled into the homes of those with TB and worked to get a hospital for indigent patients with TB. Rabbi William Sterne Friedman also saw the need for such a hospital. Rabbi Friedman worked with the established Jewish community in Denver and was able to amass enough money to contribute to the establishment of National Jewish Hospital in 1899. Unfortunately Frances Jacobs died of pneumonia in 1892 and did not see the establishment of the new hospital.

The establishment of a hospital dedicated to the care of those with TB spawned facilities to care for family members of TB patients. The Hofheimer Preventorium was established to care for the children of TB patients with the thought that children may be more susceptible to the medical and psychological consequences of having parents or adult loved ones with TB. It was noticed that many of the children had breathing difficulty associated with wheezing and National Jewish doctors took an interest in asthma.

The history of National Jewish becomes diverse and wonderful as it spawned many investigators through history involved in TB, asthma and eventually pulmonary fibrosis, occupational lung diseases, and now nontuberculosis mycobacterial lung disease. It is also becoming involved in lung cancer research and care.

But National Jewish wasn't the only institution dedicated to TB care in the late 19th century since Denver was as diverse a community as was the United States. The Jewish Consumptive Relief Society established a sanatorium, Lakewood San., for the more destitute Eastern European Jewish population emigrating to the area, and the Swedish National Sanitorium as well as the Evangelical Lutheran Sanitorium were also developed around this time. Prior to antibiotic therapy sanitoria were the centers for TB care and Denver was an active region of the United States in this regard.

Today in Denver it is clear and sunny and the mountains are out in regal splendor.

Sarcoidosis v. berylliosis in Denver

I haven't forgotten about the blog but I also haven't figured out how to present cases without infringing on the trust of National Jewish. My sponsers, Chuck Daley and Mike Iseman, are out of town this week so I am busy but without direction on how much I can discuss on a blog. I may have to stay more general , for the time being, in discussions of tuberculosis, non-tuberculous mycobacterium lung disease, interstitial lung disease and occupational diseases.

Interesting thoughts from occupational lung disease include a rising exposure of beryllium in this country and how our sarcoidosis patients may actually have berylliosis, rare but not nonexistent. The occupational clinic at National Jewish sees sarcoidosis patients, not the pulmonary docs. An odd distribution of disease, maybe due to suspicion of berylliosis exposure in these patients.

Sarcoidosis is rather common in clinic and strikes patients at a young age, 20-40. It is characterized by big lymph nodes that are usually uniformly distributed in the center of the chest and "lumps" in the lungs. It seems to affect African-Americans and people with Scandinavian decent in the United States leading some to believe that it may be related to a deficiency of vitamin D. But no one knows exactly why it occurs.

Berylliosis presents just like sarcoidosis in the lungs. Beryllium is a metal used in the aerospace industry, nuclear industry and sometimes manufacturing of radiologic equipment and dental equipment. If someone were to show up to clinic in Seattle with "sarcoidosis" and they worked for Boeing or in dentistry I may be inclined to test for berylliosis. It is estimated that about 800,000 people may have beryllium exposure, up from about 30,000 exposed in the 1970s. The test is for beryllium induced lymphocyte proliferation on BAL fluid or from blood. BAL fluid test is more sensitive. The treatment is steroids and removal from beryllium exposure. This is a workman's comp issue.

Denver is a little down since their baseball team, the Rockies, lost their chance to go to the World Series to the Philadelphia Phillies, Jamie Moyer's current team. I can see the stadium from my apartment with the Rocky Mountains in the background. It's good to have a view.

Casper, WY and Snow

First things first, the Minnesota Twins have played their last game in the Metrodome tonight. They lost three straight to the New York Yankees and they are into a new outdoor stadium next year. Got to watch them excavate home plate so they can move it to the new stadium. Although the Twins won two world series in the Metrodome it was not a great stadium to watch a ballgame and it will be refreshing to visit the Cities to see outdoor baseball in 2010.

I woke up to eight inches of snow in my room at the Hilton Garden Inn in Casper, WY. today. Actually, the snow wasn't in my room but outside. I did wake in my room though. It is October 11 everyone...October 11! The snow scrapers were sold out at the convenience store so I used a copy of the Cheyenne Sunday paper to remove the snow from my car. I chose to go barehanded in my snow removal since I couldn't find my gloves. Ah, that feeling of numb hands in the near dark removing snow from the hood and windshield, can't beat it in the morning. Got coffee and a donut and hit the road.

Driving in the blowing snow on packed ice and road snow is an art and not so much of a privilege. It was stressful for about 2 hours before I stopped for breakfast. The snow was swirling on the road and around my car like an art piece and when trucks passed they swirled up enough of the stuff leaving me in a white out world for what seemed like hours at a time. Knowing there were cars in front of me without being able to see them while going 60 mph left me thinking of the times that I had to drive from St.Paul to Ames, IA, where I went to college, in the winter.

I got to remember my trip through Sheffield, Iowa when I was a senior, as I was dodging snow ruts in Wyoming. Then, in 1981, I had a 1972 Plymouth Sattelite with rusty fenders and a hood that eventually came off while I was driving. While I still had my hood though I was driving with another student that I didn't know very well, a commuter from the Twin Cities like myself. She shared in gas money. We were caught in a blizzard in December with trucks jackknifed in the ditch and every mile being a white knuckle experience. We had to get off the road in northern Iowa or die. It happened that Sheffield was close, a community of three bars and a gas station. It was mid-day and we limped into one of the bars. It had some heavyweights in it at noon and the TVs had rodeo going, as it turned out, all day. I was too nervous to drink and my friend was freaking out. We had to stay in the bar until the evening, talking and watching rodeo. By evening we were both exhausted without prospects for sleeping, the blizzard continued to rage. So I asked the owner if we could plan to stay in the bar until morning. He was concise in his answer, "F--- no". There seemed no chance for negotiations, so I asked a woman at the end of the bar if she knew where we could stay. She said we could stay in her apartment above the bar and showed us the way up the wooden stairs on the side of the building. It was ef'en cold. My friend got a two seater couch and I got a kitchen chair. Our host went back to the bar to return later. While she was getting ready to go to bed a friendly male patron of the bar came up the stairs...clomp...clomp...clomp...stamp, stamp (to get snow off his boots, polite guy). He wanted to know if she was OK. She was, and they went to her bedroom, just ten feet from where I was sitting upright in my kitchen chair pretending to sleep. She said that she didn't do this much but she lives above a bar and has two complete strangers in her small apartment. I think she may do it much but I was young and foolish, and I wasn't casting dispersions, just questioning her. They were active in there, and verbal, and her bed squeaked. I felt like I had appendicitis and didn't sleep a wink. When the sun came up, and the storm abated, my friend and I left without poking our head in her bedroom to say goodbye. I think we left some money since was strangely kind to help us, but MY GOD! We hit the road that was littered with car and truck carnage.

I got to relive this experience driving today in the blowing snow through Western Wyoming. I vowed not to stop.

Now I'm comfortable in Denver after spending time with my friend Tim and his daughter Peggy who tonight announced that she was changing her name to Meg.

This has been the travel portion of the expedition, tomorrow I start in Asthma Clinic at National Jewish. 1400 miles in three wonder packed days and it was great fun.

Seattle to Denver and National Jewish

I am going to Denver to study at National Jewish Health Center for lung disease and in January 2010 I will go to Philadelphia to study at the Penn Center for Biomedical Ethics. This blog will bring you the highlights of my travels and my work with doctors internationally known in their specialties. I want to make this a travel log and a description of medicine as a nurse or intelligent lay person might understand it. I am dedicated to all the nurses that I have worked with through my life. Generally, they take care of the patient as doctors take care of the disease.

I left Seattle on Thursday, Oct 8, 2009 at about 3PM and made it to Spokane for the night. I stayed in a Red Lion in that smelled like a new car but the bed was firm. I ate a steak, a common theme on my trip through Montana and Wyoming, and went to bed. If too excited by now you may want to take a break.

Spokane is the home of the basketball power Gonzaga and Scott Bonvallet, a friend and former colleague. His dad is a thoracic surgeon there.

The next morning I hit Idaho and decided to use my new hands free, stereo Blue tooth system in the new Acura MDX that I bought last week. It smells like a new car too, since it is a new car. Anyway, I called Fox Talk Radio since my new car has XM radio. They were blathering on about how Barack Obama didn't deserve the Nobel Peace Prize, announce that morning, and asked for callers to state why he deserved this prize. Well...it's not like he applied for it and in fact he stated that he didn't think he deserved it but got it and that's that. I was calling to say that he may have been the only one in the world that deserved it this year. Certainly the Dali Lama has won enough and Ahmanidijadh(sp?)isn't quite ready yet. So that was my argument and the pre-screeners bought it so I was waiting to get on the air when I hit a mountain pass and lost contact with civilization and with FOX news.

I looked forward to getting to Montana. While going through Idaho I almost hit a big-horned sheep that was grazing on the grass in the meridian. A Dodge pick-up had to swerve out of its way as well proving that it was not willing to take one of those things on face to face. Along the way I also saw many hawks, roadkill and of course cattle in Wyoming. I also saw aluminum animals on the roadside in parking lots and yards.

Last night I stayed in Bozeman, MT and enjoyed it. Montana State was celebrating their homecoming so there were about 50 people on Main St. at a pep rally. The cheerleaders were wearing snowmobile suits since it was 22 degrees F and snowing. The PA system was giving feedback and generally it didn't seem that successful. The Bobcats played Northern Arizona today but I don't know the score. I hung out in a cool place called, I think, Buffalo Jim's. After a drink I had a great bison steak...tender and juicy. It reminded me of a fun fact I used to bring up on rounds at Overlake. Bison, or buffalo, only have a solitary chest cavity so if you shoot an arrow into one side both lungs go down and the animal drops like a sack of flour. The plains Indians took great advantage of this with arrow technology.

Along the way I listened to an array of music including artists like Radiohead, Marcy Playground, the Ramones, Keith Urban and Kenny Chesney. Since I had XM radio I listened to the Twins lose as well as the Cardinals and I heard Eric Gottesman's (friend and former partner) wife Jessica DJ a country western channel. Hear "Jessica Wade" on channel 16 and 17 on the XM country western dial. I called her, actually I called Eric but she was carrying his cell phone, to say that I heard her on the radio in Montana. She seemed humbled by the fame and told me that she had to put her kids down for a nap because they had a birthday party to attend later that day. Barack Obama would have said the same.

While in Bozeman I picked up a paper with some articles on wolves in the West. Apparently the government introduced grey wolves into Yellowstone and Eastern Idaho in 1998. Wolves have also migrated from Canada into Glacier Park. The hunters and farmers are pissed because these wolves don't stay put and sometimes roam into areas where they are not wanted. In 1998 there were approximately 50 in the region and now there are 500. They have ravenous appetites and are thought to eat 20 Elk a year, or 30-40 deer a piece. Note, it's my understanding that fur can be constipating. Why, I don't know. Now wolves are off the endangered species list and the farmers and hunters can have at 'em. There are 3,000 wolves in Northern Minnesota, Wisconsin and UP Michigan. There families there are asked not to leave their older relatives out overnight (Okay, if you can't take a joke stop reading).

The most depressed towns I saw were Butte, MT and Billings. I am wrestling with the pronunciation of Butte since phonically it should be...you know...two consonants soften the ending vowel and make the "ew" an"u". I don't know how they got the accepted pronunciation.

Next I landed at the Little Big Horn, just southeast of Billings about 50 miles. What a disaster for the United States military in 1876. General Custer, under the command of the Northwest regimen under General Terry was sent to put the Lakota Sioux and Cheyenne down, or at least to ask them to return to their reservation. Under a previous treaty made between the greater Sioux nation and the United States government under President Grant they were all to be place on reservations. The Lakota Sioux under the command of Sitting Bull had about 2000 warriors and Custer had 600. The Lakota and the Cheyenne were not interested in living on reservations and took it to Custer's command. On Last Stand Hill Custer and his men were eventually slaughtered. Custer was buried there but later exhumed and buried at West Point. The battlefield cite was chilling to experience. I couldn't help but wonder what some of the enlisted men were thinking as they were being led to battle in this barren and cold place. Most were poorly educated and some didn't even speak English as they were recent immigrants. What a terrible way to die so far from home, but so goes war.

I'm now in Casper, WY, a little place in the middle of cattle, buttes and rolling hills. It's snowing on Oct. 10 and the temperature is 20 degrees F. Tomorrow I'll be in Denver and ready to go to work with the doctors of National Jewish Health Center.